Tumor size and tumor stage — both of which tended to be greater in women insured by Medicaid — were independent predictors of receiving mastectomy.

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THURSDAY, April 25, 2013 (Medpage
Today) — Women insured by Medicaid were more likely to
undergo mastectomy for early-stage breast cancer than those who were privately
insured in a single integrated healthcare system, researchers found.

The mastectomy rate was lower among women with Medicaid for tumors
smaller than 2 cm but higher in that group for larger tumors, resulting in a
significantly higher mastectomy rate overall compared with their counterparts
with private, according to Joseph Sferra, MD, of ProMedica Health System in
Toledo, Ohio, and colleagues.

Tumor size and tumor stage — both of which tended to be
greater in women insured by Medicaid — were independent predictors of
receiving mastectomy, the researchers reported online in JAMA
Surgery.

"Early detection efforts, such as increasing the rate of
screening mammography among Medicaid patients, could increase the number of
patients who receive breast-conserving treatment," they wrote.

An NIH consensus statement released in 1991 indicated a preference for
breast-conserving treatment over mastectomy when surgery was performed for
early-stage breast cancer. That was backed by evidence from randomized trials
showing comparable survival rates using the two approaches.

Mastectomy remains a common treatment in early-stage breast cancer,
however, with reported rates up to 30 percent for stage I disease and 82
percent for stage III disease.

To explore the effect of insurance status on the choice of surgical
treatment, Sferra and colleagues performed a retrospective analysis of data
from 1,539 women who underwent surgery at ProMedica for stage I to III invasive
breast cancer from 1996 through 2009. Overall, 42 percent of the women had a
mastectomy and the rest had breast-conserving surgery.

At presentation, tumor size was significantly greater among women
insured by Medicaid than among those with private insurance. And the percentage
of patients who presented with stage I tumors was lower in the Medicaid group.
Both findings are consistent with previous studies showing that women with
Medicaid typically present with later-stage disease.

Overall, breast-conserving surgery was the treatment chosen by the
majority of women with tumors less than 2 cm, whereas mastectomy was chosen by
most for tumors 2 to 4 cm and larger than 4 cm. The trends were similar when
the tumors were broken down by stage.

But insurance status came into play, as well.

Unlike for larger tumors, for tumors less than 2 cm, patients with
Medicaid were less likely to undergo mastectomy compared with women with
private insurance, which could be related to patient choice or surgeon
preference, according to the researchers.

"Surgeons are reimbursed 40 percent less for breast-conserving
treatment than for mastectomy," they noted. "Reimbursement does
impact what surgery is performed for early-stage breast cancer. Surgeons may
not be incentivized appropriately for providing less-invasive procedures of
equal efficacy."

"Understanding the effect of reimbursement models on the
treatment of early-stage breast cancer may reveal targets for overall quality
improvement [and] this may mean increasing the number of specialists,"
they added.

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